Medicare Compliance & Reimbursement

Last week, CMS opened the door to new payment rules governing prothombin time testing, and this time, the new rules expanded coverage, rather than restricting it.

Medicare will now cover prothombin time international normalized ratio (INR) for patients using warfarin to treat chronic atrial fibrillation or venous thromboembolism. In the past, Medicare allowed home testing coverage only for beneficiaries with mechanical heart valves who took warfarin.

Under the new policy, "the patient would have to first be anticoagulated for three months or longer before implementing home monitoring," says Nicole Smith, CPC-CARDIO, E/M, of Spokane Cardiology. "Education has to be provided to the patient about how to use the monitoring device, and home-testing shouldn't be done more than once a week," she says.

Keep in mind: You can collect for the patient education session when teaching the patient how to use the home monitoring device. "The 2008 HCPCS Level II manual describes these services in depth," says Christina Neighbors, MA, CPC, ACS-CA, of Franciscan Health Systems in Tacoma, WA. Those codes are as follows:

• G0248 -- Demonstration, at initial use, of home INR monitoring for patient with mechanical heart valve(s) who meet Medicare coverage criteria, under the direction of a physician; includes demonstrating use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing (Initial service/charge)

• G0249 -- Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meet Medicare coverage criteria, includes provision of materials for use in the home and reporting of test results to physician; per 4 tests (Additional service/charge per 4 tests)

• G0250 -- Physician review, interpretation and patient management of home INR testing for patient with mechanical heart valve(s) who meets other coverage criteria; per 4 tests and does not require face-to-face service.

In some cases, the patient may present to the practice for testing rather than perform the test at home, which you should code differently.

Many physician offices have a designated area called a "Coumadin clinic" where the physician can assess the patient's clotting time using a lab test that you'll report with 85610, Smith says. "For most patients, this is performed every four to six weeks. The test data will show if clotting time has fallen below the target range medication, then dosing is increased," Smith says. "When it goes above the target range medication, then dosing is decreased."

In some cases, the physician will need to counsel the patient on other factors that can impact clotting, such as exercise, diet and other medications. "Sometimes it is appropriate to report a low-level E/M visit code 99211 with lab test code 85610 if there is medical necessity," Smith says. "Your documentation must state that the patient had a specific problem, as well as any complaints or signs and symptoms."

For instance: A 75-year-old male patient who has atrial fibrillation comes in for Coumadin monitoring. During questioning, the nurse discovers that he has been taking a 5-mg tablet daily, although his prescription calls for a 5-mg tablet on Mondays, Wednesdays and Fridays and a 7.5-mg tablet the other days. The nurse not only monitors his Coumadin levels to determine this lapse's effect, but also counsels the patient on Coumadin's proper administration after confirming dosages with the physician. In this case, documentation would support medical necessity for 99211 as well as 85610.

Read the new coverage decision online at http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=209.